Skip Ribbon Commands
Skip to main content
Bookmark and Share this page


Remarks before the George Washington University Global Summit on Regional Aviation Oversight, Washington, DC, February 2, 2005
Ellen Engleman Conners
George Washington University Global Summit on Regional Aviation Oversight, Washington, DC

It is my privilege to serve as the 10th Chairman of the NTSB. I follow a noble line of predecessors, including FAA Administrator Marion Blakey and I am grateful that I work with fellow Board members who share in my commitment to safety - Vice Chairman Mark Rosenker, formerly of the White House Military Office, Member Carol Carmody, formerly with the FAA and our representative to ICAO, Member Dick Healing, formerly of the US Coast Guard and private sector and Member Debbie Hersman who recently joined the Board from the Senate Commerce Committee.

I am delighted to meet such distinguished guests as ICAO Sec Gen Dr. Taieb Cherif and Dr. Assad Kotaite, President of the Council and the many state and industry delegations from all over the world. And I want to particularly thank Professor Vahid Motevalli, Director of the George Washington University Aviation Institute and Director of the GW Aviation Safety and Security Consortium. The presence of each of you illustrates the global nature of aviation and air transport.

I come from the surface transportation world, and before I even begin my remarks I want to thank each of you as well as many of the aviation organizations -- including the FAA and Boeing among others, for the warm welcome and support you have given me during my time as Chairman. Many of you have helped me learn this brave new world and welcomed me warmly. But I also come to you with perhaps a perspective that will serve us all well as we seek ways and means to work together for safety. I believe strongly that our transportation system is intermodal, international and inter-related. What happens in one mode will affect others. What we can learn in one mode may help others. When the Port of Los Angeles was closed in 2002 due to labor/management issues, it cost a billion dollars a day, affected trade throughout the world and shifted transportation responsibilities to other modes. When SARS broke out, the interconnectivity of our transportation system was potentially an incubator to help spread the disease. And the greatest example of all, September 11, 2001 when terrorists used the American transportation system as a weapon of choice - impacting world air travel permanently.

So I hope you will agree that our transportation system is intermodal, international and interconnected. So how does that impact safety? First, we must seek commonality and share lessons learned whenever possible and practicable. As Administrator Blakey pointed out so well in her comments to you yesterday, there is, indeed, safety in numbers. As she stated "that's why we've come together - with a common vision and a common goal and our work becomes a platform for us to build partnerships that spread and solidify safety across the globe." Administrator Blakey eloquently summarized a noble and shared goal. Our job, is to continue to find the path, to develop the map, identify the means and share the methods that will support a total approach to safety.

ICAO has, with great success, helped to harmonize, in a seamless way, international travel. The NTSB certainly sees tremendous advantages with ICAO initiative for universal safety oversight for all ICAO member states and we will assist, as we can, all states in fulfilling their obligations. The NTSB has a distinct obligation, as the Accredited Representative for a major aviation manufacturing state, to support all the 188 individual states in their responsibilities for incident and accident investigations as called for in Annex 13. Because of the Safety Board's status under ICAO, U.S. manufacturers and operators rely heavily upon the Board to facilitate their involvement in the investigation of foreign incidents and accidents. A major airline accident involving fatalities anywhere in the world causes significant concerns on the part of the traveling public; both in the U.S. and overseas. The Board's involvement in the investigation of major international accidents assists in reducing these concerns and provides a critical contribution both to U.S. foreign relations and to strengthening the Nation's balance of trade posture through aviation exports.

In last two years, NTSB has assisted in 31 international accident investigations. As we reach down into the real-time reality of an accident investigation, however, we find that there are regional needs that need REGIONAL solutions. And so, we can also support cooperative approaches to Regional Oversight. Local knowledge, local culture and the local capabilities can make the Universal Safety Oversight Program work to its best advantage.

The Safety Board's workload has also increased over the last several years because of its obligations under Annex 13. The Board must investigate any accident worldwide in which the United States was the State of the Operator, State of Manufacturer, or the State of Design. Because of our role to oversee U.S. economic interests in the event of a foreign accident involving a U.S.-operated or -manufactured airplane, we must be partners in safety.

Now how can an independent agency be a partner in safety? Well first you must define independence. And I will define it in reverse to make my point. Being independent does not mean being adversarial. Being independent does not mean working in solitude. Being independent does not mean rejecting cooperation, communication or common goals.

The NTSB is fiercely independent. We are, by Congressional design, an independent agency. That means that we are a separate entity from the executive branch organizations such as the Department of Transportation. But, we are still an agency of the US government, paid by the US taxpayer and we are accountable to them. Our investigations are independent in that we have the legal responsibility to conduct the investigations without undue influence or oversight by others.

Now you will ask me, Chairman, how does an agency of only 400 plus people, a budget of under $80 million dollars conduct over 2000 investigations each year? Well, first, our secret to success is based in the hearts of our employees. The employees of the NTSB do not have a job - they have a mission - and each one is personally committed to safety. Secondly, we fortunately have a unique system called the party system that we utilize to support our investigations. Under the party system, the NTSB can request or accept the assistance of an entity or organization that can offer technical assistance to the investigation. Thus the manufacturer, the airline, etc. participate via their expertise. The party system does not include insurance companies or lawyers, for example. And the safety investigation is always separate from other parallel or concurrent investigations that focus on other issues - whether they are issues of liability or criminality. Our ability to utilize the party system is a benefit to the NTSB as long as the integrity of the party system is preserved. That is to say, we will vigilantly guard against organizations and entities attempting to exert undue influence or use the system for other purposes.

But it is this system of relationships that give us strength, that builds our body of shared knowledge - and that is why I say that our independence does not mean that we do not work with others to achieve our safety goals.

The Safety Board continues to be deeply involved in overseas accident circumstances by sending investigators to the scenes of selected accidents and by monitoring the progress of other countries' investigations closely. Our staff maintains a close liaison with the investigation authorities of many countries, even for cases not involving U.S. airlines or U.S.-manufactured aircraft. For example, if a foreign-registered aircraft manufactured in France, Britain, or Holland, etc. crashes in another country, our staff monitor the accident findings for possible development of corrective actions for U.S. operators.

While our investigator staff carries out their duties on a global basis, we have historically assigned some of our investigators to place special emphasis on assistance at a regional level. For instance, Dennis Jones has considerable experience in the African continent, is recognized by our counterpart accident investigation agencies there, and is in a frequent supportive role for incident and accident investigations and safety promotions within that region.

Within the Latin American Region, our Regional Director of the NTSB Office in Ft. Worth Texas, Mr. Hector Casanova, provides the eyes and ears of the Safety Board to the south, having just recently returned from Argentina where he was a guest instructor at the National Accident Investigation School.

For many years, our Northwest Regional Director, Mr. Keith McGuire, has led delegations to the Asian region for safety seminars. As we speak, the NTSB Academy is hosting a high level group of investigators from China on a 10-day course in investigation. Within a few months we expect this initiative to expand, with ICAO-COSCAP support, to a regional program to further professionalize the safety improvements in the Asian region.

So what happens after the accident investigation is concluded? At the NTSB we issue our final reports, voted on by our Board, that offer our determination of the probable cause of the accident - note that I didn't say who was at "fault" - that is a different question for a different venue than ours. We are focused on what happened and why so that it will, hopefully, not be repeated. To accomplish this, we then issue our safety recommendations. As some of you may have heard me say, the NTSB does not give out money or make the regulations. We have only what we call a bully-pulpit - meaning we must preach safety based on our reputation as having the independent technical expertise to make these determinations and then shout to the heavens. Only in our case, we send out letters. These letters list our safety recommendations to the appropriate recipients based on what we found in the accident investigation that we believe needs to be changed or improved, created or issued to ensure that the elements of this accident do not occur again. Since our creation, the Board has sent out over 12,000 safety recommendations - and we have an acceptance rate of over 80%. That means that eventually over 80% of our recommendations are implemented. A good record. However, time matters. And all too often these safety recommendations have languished - sometimes taking 2, 5, even ten years for a response. I believe very strongly that our job is NOT done until our recommendations are implemented.

And so, during my tenure as Chairman, I have taken an initiative that Administrator Blakey began when she was Chairman; that of going to the individual modes within the Department of Transportation to discuss their progress - or not - on NTSB recommendations. We have instituted a SWAT approach - that stands for Safety with a Team in which, at a staff level, we actively communicate with the recipients of our safety recommendations to find solutions, find common ground, and to get the job finished. That is our focus -- to find out why safety recommendations have not been implemented and focus on what must be done to get them implemented. Do we lower our standards? No. Do we compromise our view on safety? No. Our independence is like the fence between your house and the neighbor's house. The fence is always there, deeply secured in the ground by hard driven stakes, but -and herein lies the key - but, you can and should still talk to one another. And so we talk, and we learn, and we find out in so many cases that our recommendations were being implemented - but perhaps in an alternative way than we initially offered or we find out that the issue has been superseded by other events or we even find out that the recipient didn't understand what we meant? Sometimes we just duke it out around the conference table - but we are getting results and results and performance man it's a safer transportation world. We have had great success. Why am I so concerned about performance and results? Because the safety chain is not complete - the lessons learned from the tragedy of an accident must be implemented - not just listed on a piece of paper. Out of tragedy good must come.

The industry forecast for aviation accidents indicates that the number of accidents will increase as air traffic volume continues to increase worldwide. At the end of last year, 17 major US airports had returned to pre 9/11 operating levels. The number of air carrier aircraft is expected to increase from the about 15,000 currently to 25,000 by the year 2015. Additionally the increase in Air Cargo is substantial. US Secretary of Transportation Norm Mineta recently shared the "State of Aviation" at the Aero Club in Washington where he stated that "in the US alone, air freight is the fastest growing segment of the US cargo economy, carrying cargo valued at $2.7 BILLION, yes, Billion, dollars a day." He added, " from passengers to operations to air cargo, we could see three fold increased in the next 25 years."

The US has had a three-year safety record without a major commercial airline accident. However, in the last two years the NTSB has assisted in 31 international accident investigations in Mongolia, Nova Scotia, Rome, Panama, Egypt, Bosnia and Indonesia among others. If the worldwide accident rate stays the same, some analysts predict that, by 2015, a major aviation accident will occur somewhere in the world each week. Statistics also show that cargo flights have a 2-5 times greater accident risk than for passenger flights. The NTSB has responded to three cargo aircraft accidents in the last six months and recently hosted an Air Cargo Forum at the NTSB Academy with over 150 industry attendees to discuss issues, identify the barriers and challenges and begin what I hope is a dialogue for safety. A dialogue for safety is critical for ultimate success. Dialogue, communication and cooperation must be the foundation for all safety progress- whether they are with the NTSB and the recipients of our safety recommendations through our SWAT process or among the ICAO members in their deliberations. We must learn from one another so that lessons learned are lessons shared.

Lessons we have learned tell us that the causes of overseas accidents do not vary substantially from the causes of U.S. accidents. That is, the majority of the causes involve some combination of human errors, mechanical failures, design deficiencies, maintenance problems, adverse weather, and so forth. There are no regional issues like European icing, or Asian fatigue. The lessons learned from virtually any airline accident can be applied to improve the safety of other operators. Dissemination of safety information that emerges from overseas investigations is invaluable to the NTSB. And we will continue to maintain close communications with the Air Transport Association member airlines' safety officials, airframe and engine manufacturers, the FAA, pilot and flight attendant unions, etc. to ensure lessons learned are lessons shared.

The Safety Board has issued numerous recommendations to the FAA concerning airworthiness and operational problems that were discovered as a result of the investigation of foreign accidents. Additionally, as a result of foreign accidents, the Safety Board has worked with the airlines and manufacturers on serious incidents to correct practices that did not cause or result in an accident but was believed not to be in the best interest of aviation safety. We are all partners in safety - in our intermodal, international and inter-connected world of transportation.

The NTSB is committed to this safety partnership and, as mentioned by Professor Vahid Motevalli last night at dinner, we have the new NTSB Academy on the George Washington University campus as a major new tool in our safety tool kit. The NTSB Academy has been opened for only one year - and yet, in one short year, we have already added to the safety body of knowledge through our training courses and outreach. We have offered over 15 training courses to over 1000 students, including students from 35 other countries. We have held two safety forums - the air cargo safety forum mentioned earlier and one on personal floatation devices. We have another one planned for positive train control in March. With over 67,000 square feet of conference and lecture rooms with state of the art telecommunications and laboratory space that includes the reconstruction of 93 feet of the fuselage of TWA 800, we are open for business. When I talk about NTSB investigations, I say that the NTSB's credibility is due to the fact that our investigations are based on fact, science and data - not guess supposition or desire. Our goal is to help ensure that a shared approach to accident investigation is adopted throughout the world to ensure technical consistency of approach and methodology, independent and objective analysis and fair and verifiable determinations.

We are partners in Safety and I thank you for your attention, interest and support of our efforts at the National Transportation Safety Board. We wish all the participants at the Global Summit the best of success - and will continue to work with the ICAO Regional Initiatives at every opportunity.